Most Challenging Field of Pathology

[Enkidu]

I know that every field of pathology has its fans, and that factors like reimbursement and lifestyle play a role in people's preferences, but I'm wondering which field of pathology enables you to make the most interesting and challenging diagnoses.

My sense is that hemepath may have the most fine-grained conditions to diagnose, but that's based only on a couple years of med school.

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[pathstudent]

I know that every field of pathology has its fans, and that factors like reimbursement and lifestyle play a role in people's preferences, but I'm wondering which field of pathology enables you to make the most interesting and challenging diagnoses.

My sense is that hemepath may have the most fine-grained conditions to diagnose, but that's based only on a couple years of med school.

The most interesting and challenging areas of pathology are Neuropathology, Pediatric Pathology and Soft Tissue Pathology.

 

[2121115]

No field has more challenging cases than another. Some fields just have less common specimens (less volume) and fewer pathologists know about the entities. But to a well trained pathologist in each discipline, they have the same number of hard and easy cases.

 

[Enkidu]

The most interesting and challenging areas of pathology are Neuropathology, Pediatric Pathology and Soft Tissue Pathology.

Hey pathstudent,
Thanks for the answer. I thought that soft tissue pathology seemed really interesting as well, and I'm a little invested in neuropathology through my research. Could you go into a little detail as to why these three areas of pathology are more interesting/challenging?

 

[caffeinegirl]

Everybody has different fields that they gravitate towards, and different fields that they find challenging and interesting...you figure it out during your rotations in residency. My program had subspecialized sign out, so I was able to get a real feel of what the lives of attendings in each field were like, and what that specific specialty was as well. I gravitated towards high volume specialties with a variety of disease processes (neoplastic and inflammatory)..others gravitated towards organ systems they were comfortable with...I think that there isn't a right answer to the OP's question.

 

[Enkidu]

Everybody has different fields that they gravitate towards, and different fields that they find challenging and interesting...you figure it out during your rotations in residency. My program had subspecialized sign out, so I was able to get a real feel of what the lives of attendings in each field were like, and what that specific specialty was as well. I gravitated towards high volume specialties with a variety of disease processes (neoplastic and inflammatory)..others gravitated towards organ systems they were comfortable with...I think that there isn't a right answer to the OP's question.

Hi, I realize that different people gravitate towards different fields, but not everyone gravitates to the field that they find most interesting/challenging. Some people may find hemepath most interesting, but go into dermpath for the higher income. In my case I think I will pursue neuropath because of my research involvement, but I can imagine being more interested in signing out soft tissue. As for there being a "right answer", that's okay, I'm just looking for opinions.

 

[lipomas]

Everything is challenging if you don't understand it well or see it a lot. And almost everything becomes easier if you see it a lot or are very knowledgeable about it. Medical lung is challenging to me because I don't see that much of it.

Just because someone like pathstudent says neuropathology is more interesting doesn't make it so for you. But if you think it is more interesting then that does make it so. I don't like dermpath. I don't find it interesting and 90% of it is not challenging. But others disagree and find it all challenging and interesting.

 

[KCShaw]

All pretty true. Eye of the beholder, and all that. Personally I found heme and soft tissue relatively challenging once one got past common/classic things, and there's a lot of art in the immunos. I think a lot of neuropath can be subtle unless you look at a lot of brain, and therefore challenging. On the other hand I found pediatric path fairly interesting, as well as most non-tumor stuff. But for unusual and interesting, as well as challenging in its own niche way, I still think forensic path is hard to beat. And yes, I'm biased.

 

[Enkidu]

Thanks for your responses so far. Let me clarify what I'm asking a little to make it less subjective. I'm thinking about two different axes:

1) The number of conditions that are diagnosed by pathology, regardless of how rare. e.g. Field X encompasses hundreds of disease entities, whereas field Y encompasses dozens

2) The actual chance of seeing most of those conditions. e.g. Even though Field X encompasses however many conditions, pathologists in this field diagnose 3 different common conditions constantly and almost never see anything else

My thinking is that the more conditions that must be mastered and the less routine the diagnoses are, the more "challenging" the field is, even though a specialist in the field may not describe it in that way.

One reason that I'm asking this question is that I'm trying to decide which field of pathology to do my next preceptorship in and I want to get a sense of which fields people consider to be "challenging" in the way that I described. I don't want to just pick an organ system that I enjoyed in medical school, because the actual practice of pathology in that field may be completely mundane.

 

[malchik]

Compare the thickness of the respective WHO books. I think heme wins by that criterion.
Number of diagnoses is quite large and getting larger, because of splitting and definition of entites based solely on molecular criteria. One could argue that the lumpers in the field (far fewer than splitters probably) would just say, well, it's still B cell lymphoma.

Likelihood of seeing all these entities depends largely on the practice type, if it is a referral center or not, that kind of thing.

 

[zao275]

Agree with most of the previous comments. It depends on multiple factors and there is no one right answer. I think most people find soft tissue very challenging because there are a wide variety of entities and they are fairly uncommon (to downright rare). But, as has been said, if you see a lot of these things it becomes much easier. As a soft tissue fellow, I have seen about 3,000 soft tissue cases so far, so I feel pretty comfortable with a lot of these (although it seems like I see cases that are tough and confusing every day).

Enkidu, to answer your question mathematically, I would say dermpath has one of the most extensive lists of possible entities. Perhaps much of this is due to the love of the derms/dermpaths to split, rename, and reclassify things (heme shows similar traits, although with their molecular data, they probably have a better excuse for doing it!). However, I am biased, as I am doing dermpath fellowship next year and I love skin.

Interesting discussion topic. Nice post.

Jerad

 

[Circumflex]

Although I don't remember the exact reference, a few years ago, there was a paper published showing a huge diagnostic discordance rate among neuropathologists. Cases were sent to several well-known NPs and the diagnoses were all over the place.

This happens with other specialties (particularly soft tissue), too. The subjective nature of some of our diagnoses is definitely challenging.

 

[zao275]

No, no. Soft tissue pathologists ALWAYS agree on everything.

 

[KCShaw]

It's relatively easy to be good at a niche subspecialty. It's hard to be good at everything, like a top notch general surgical pathologist. It's also kinda out of vogue and carries an air of old-school about it, but most of the "great" pathologists were/are exactly that, even if they had/have narrower areas of particular interest/more publications. Being good enough that subspecialists from different areas are willing, or forced, to accept you as a peer.. -that- is challenging.

Of course, diagnosing an isolated specimen or slide is boring! Try starting with the whole body, and invoke CP pre- & post-mortem results as well as the more typical AP, and mix in more history and circumstances, and you've got something interesting and challenging..